Please identify the person who will serve as the "Practice Manager" for the US Wound Registry:

Name

FirstMiddle (or Initial)LastSuffix (opt.)Credentials (opt.)

Address 1:

Email

Address 2 (opt.):

Phone #:

City:

Fax # (opt.):

State:

Are you a submitting provider?

Zip Code:

NPI (if applicable):

Consent and Agreement

Data Collection Agreement Cover Page

The attached documents describe the relationship between Chronic Disease Registry, Inc. d/b/a U.S. Wound Registry (“CDR” or “USWR”) and the independent physician or physician practice identified above (“Physician”) each a “Party” or collectively the “Parties.” The documents attached to this form will consist of the document entitled “Master Terms” (the “Master Terms”), which describe and set for the general legal terms governing the relationship and one or more Addenda describing and setting forth further covenants of the parties, depending on the obligations and services to be performed by each of them (collectively, the “Agreement”).
This Agreement includes this Data Collection Cover Page (the “Cover Page”), the attached Master Terms and all Addenda that are attached to the Master Terms. This Agreement, including the attached Master Terms, will become effective when this form is signed electronically below, if the Physician consents to ESign below, or when executed by the authorized representatives of both Parties in hard copy if ESign consent is not provided, and payment is received (the “Effective Date”).